Health Services (Health Service Establishments) Regulations 2024

For the purpose of ensuring the quality and safety of health services provided at a health service establishment, the proprietor of a health service establishment must prepare health service establishment protocols in accordance with this regulation.

The health service establishment protocols must be—

documented in writing; and

made available to the public—

on the health service establishment's website; or

in the manner and form determined by the Secretary; and

made available to the Secretary on request.

The health service establishment protocols must include the following—

processes for assessing every 3 years the credentials of each health professional practising at the health service establishment;

processes for setting the scope of practice for each health professional practising at the health service establishment;

processes for continually assessing the competence and performance of each health professional practising at the health service establishment;

processes for continually assessing and reviewing health services provided by each health professional practising at the health service establishment;

processes for continually assessing the capacity of the health service establishment to provide safe, patient‑centred and appropriate health services to patients at each of its premises;

setting the frequency of, and procedures for, meetings of any committees of the health service establishment with responsibility for the quality and safety of health services provided at, or from, the health service establishment;

processes for ensuring that appropriate arrangements have been made for evaluating, monitoring and improving the quality and safety of health services provided at each premises of the health service establishment;

on and from 31 August 2025, the description and allocation of quality and safety roles in relation to the health service establishment;

on and from 31 August 2025, having regard to the kind or kinds of health services being provided at, or from, the health service establishment, processes and procedures for the following—

the availability of appropriate adjunct diagnostic services;

review of adverse patient safety events, including participation of all relevant personnel in the review (whether employees or not);

addressing the specific needs of Aboriginal persons;

recognising and responding to deteriorations in the condition of patients.

The proprietor of a health service establishment must ensure that the health service establishment's quality and safety protocols are implemented and complied with.

In this regulation—